North Shore Hospital report - New Zealand Doctor

Health and Disability CommissionerOn April 6th she underwent surgery.Her condition deteriorated and she died on April 14th. (No concerns have been raisedabout her second admission.)[Mrs B] [Mrs B] arrived at North Shore Hospital ECC at 8.20am on July 6th, 2007. She had beentransferred from [another country], via Auckland International Airport, having suffered asevere stroke while on holiday.On arrival it appears [Mrs B] was poorly responsive, although her son‘s statement notesthat she acknowledged the presence of loved ones by nodding and fixing her eyes. She was placed in the ―Monitored‖ area. [An] RN, ECC, looked after [Mrs B] for 40minutes in Monitored, then transferred her to another section. The 40 minutes included a10-minute handover from the transfer team, and then she did an ECG and took bloodsamples. (It is worth noting that the initial ECG showed ST elevation in leads V 2– V 4 andthe blood test at 8.30am revealed a TNI of 2.29. These results suggest [Mrs B] had anacute myocardial infarction sometime in the prior week to 10 days, and no more recentlythan a few hours prior. Most likely the time of the myocardial infarction was somewherebetween 10 hours and a few days prior to arriving in New Zealand. I am unaware if thisdiagnosis was made [overseas] or if it happened en route.)[Mrs B] became short of breath, due to congestive heart failure. It is unclear when thisbegan, but it appears it was between 12.30pm and 1.30pm ([Mrs B‘s] son notes she wasstable and resting at 12.30pm, but he was called at 1.30pm to be told she was breathless).Her admission note states: ―CHF on lasix (frusemide) now. Fever and increased WhiteCell Count, ?aspiration pneumonia‖. These suggest she arrived with significantcontributors to breathlessness, although it appears it worsened soon after arrival (after12.30pm) and then again on the 14th.[Mrs B‘s] family raised two concerns about this phase of [Mrs B‘s] care:o The handover from the medical escorts to ECC staff — needed to repeat the history toseveral providers.o [Mrs B] was in a supine position in ECC when, because of her breathlessness, sheshould have been propped up.After medical assessment in ECC [Mrs B] was given intravenous frusemide at 1.30pm, totreat her congestive heart failure. The congestive heart failure was considered to be thecause of her shortness of breath. (The congestive heart failure is likely to have beensecondary to the acute myocardial infarction mentioned above). At 4.30pm she was transferred to ward 11.On July 14th [Mrs B‘s] shortness of breath was perceived to be significantly worse andthe family requested medical review. She was found not breathing later that night.[Mrs B‘s] family raised these concerns about this phase of her care:o Delay to on-call House Surgeon review on the night of her death (6 and a quarterhours).o Nursing shortages, slow response times, rudeness and failure to appreciate [Mrs B‘s]deterioration.114April 2009